Clinical Research StudyPeriprocedural Bridging in Patients with Venous Thromboembolism: A Systematic Review
Introduction
Among >6 million individuals in the United States who are on chronic anticoagulation, about 250,000 patients each year need to temporarily interrupt their anticoagulants prior to an invasive procedure to diminish the risk of excess periprocedural bleeding.1 Despite the rapid adoption of direct oral anticoagulants (DOACs) in recent years, vitamin K antagonists (VKAs) remain the most frequently prescribed anticoagulants in the US and worldwide.2, 3 VKAs must be interrupted several days prior to a procedure to allow for regeneration of vitamin K-dependent coagulation factors and subsequent normalization of coagulation.1 Because of the concern of an increased risk of thromboembolism during VKA interruption, periprocedural bridging with short-acting parenteral anticoagulants has been recommended for individuals at high thromboembolic risk.1, 4
A previous systematic review investigated periprocedural bridging in patients on VKAs for any indication and found an increased bleeding risk in bridged, compared with nonbridged, patients without a difference in thromboembolic risk.5 Similarly, a randomized trial of atrial fibrillation patients showed no difference in thromboembolic outcomes, but a significantly higher incidence of major bleeding with bridging compared with placebo.6 However, less is known about the risks and benefits of bridging in patients anticoagulated for venous thromboembolism. A recent retrospective study found an increased bleeding risk with bridging, but no substantial risk of recurrent venous thromboembolism without bridging, irrespective of estimated thromboembolic risk,7 suggesting that current guidelines fail to identify patients with high-enough thromboembolic risk to justify bridging.
To better define risks and benefits of bridging in patients with previous venous thromboembolism requiring VKA interruption to undergo an elective invasive procedure, we performed a systematic review comparing recurrent venous thromboembolism and bleeding outcomes with and without periprocedural bridging.
Section snippets
Methods
We conducted this systematic review according to the protocol registered on PROSPERO (registration number CRD42017074710), and reporting conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.8
Results
Our search yielded 4349 records after removal of duplicates. We excluded 4110 records based on title and abstract and then assessed 239 full texts for eligibility, of which 28 studies met our inclusion criteria (Figure). Included studies reported results of, overall, 6915 procedures, and individual study size varied between 10 and 2670 procedures (Supplementary Table 1,7,12, 13, 1418,20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42 available online).
Of
Discussion
This systematic review showed that periprocedural bridging in patients with previous venous thromboembolism considerably increases bleeding risk compared with VKA interruption without bridging, without resulting in differences of venous thromboembolic outcomes. Our results suggest that most venous thromboembolism patients will not benefit from bridging. However, the quality of the available evidence on the risks and benefits of periprocedural bridging in this population is low.
Our results show
Acknowledgments
We gratefully acknowledge Isabel Elaine Allen for her advice concerning the methodology and statistical analyses of the paper. We acknowledge Yumiko Abe-Jones and Michael Hurley for their help with translating articles, and James D. Douketis for the critical review of the manuscript and his valuable input.
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Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline
2022, ChestCitation Excerpt :Other observational studies found that heparin bridging increased the risk for major bleeding with bridging,113,114 with no significant reduction in recurrent VTE.113,115,116 In a systematic review totaling 6,195 VKA-treated patients with VTE who required elective surgery, a heparin bridging vs no bridging approach was associated with a higher incidence of any bleeding (3.9% [95% CI: 2.0-7.4] vs 0.4% [95% CI: 0.1-1.7]) and no effect on recurrent VTE (0.7% [95% CI: 0.4-1.2] vs 0.5% [95% CI: 0.3-0.8]).117 7.
Periprocedural bridging anticoagulation in patients with venous thromboembolism: A registry-based cohort study
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Funding: This study was supported by the National Heart, Lung, and Blood Institute (Grant R01HL103820 and 1K24HL141354). CB's work was supported by a grant from the Swiss National Science Foundation (Switzerland; P2BEP3_165409) and a grant from the Gottfried and Julia Bangerter-Rhyner Foundation (Basel, Switzerland). The sponsors had no role in in the design and conduct of the study, in the collection, management, analysis, or interpretation of the data, or the preparation, review, or approval of the manuscript.
Registration: PROSPERO, registration number CRD42017074710
Conflict of Interest: None.
Authorship: All authors participated in the research and preparation of the manuscript. Study concept and design: CB, MCF. Data acquisition: CB, IdK, EW. Data analysis and interpretation: CB, IdK, MCF. Drafting the manuscript: CB, MCF. Critical revision of the manuscript for important intellectual content: CB, IdK, EW, MCF. Statistical analyses: CB. Study supervision: MCF.